9907-048 (SFD)I
U)
F_
U)
04 LU
=) c)
CY
LL1
6 Z
cc) 0
(0
W UJ
EL
U)
Z
C\1
0 C\J
0)
<
Q_
2 Z
LO
0
X LLJ
0 _J
_J <
< C)
Cj o
I:C Lo
M
'j- Z
ob 5
0
_J
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect. 6
License # Lic. Class Exp. Date
Signature of Contractor
Date' 1, )z ` M
17 , ' t� — �� VVJ I �v
OWNER -BUILDER DECL-ARAT'ION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) * 1, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
I am exempt under Section _, B&P.C. for this reasorri--��
Date Signature of Owner,--- )A-\ ,A 1),
'WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ). I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
P, ldAl QW, CONIP WN976�, 56_17(;.1
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
Date: — Applicant
Warning: Failure to secure Workers' Compensation coverage is unlawful and
Shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this applicatio , n is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject pjarmit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Si Date' -1 A,
,,pature (Owner/Age'ni) 74�<A I A
PERMIT #
BUILDING PERMIT
9%)7-048
DATE VALUATION 4*223,7., LOT TRACT
.46�6(j )CI L4 L
J
1 - I t�. ( r-.�e N
JOB SITE I � V
ADDRESS 79- 0200TRUS
APN
769-670-037
OWNER
CONTRACTOR / DESIGNER ENGINEER
SUPFF0.1) HOMES
SHE.12FIri.LD HOMES
.1400 CXKCRAL AVO�UF STE 325
3400 CENTPLAL AVE'NUE, STE 325
WtVEASIDE CA 92-5045
RMUSWE' CA 97506
USE OF PERMIT
-AMILY DWELLANQ
i N 04, E F
8F0 - LOT 3 PLM iAR PERA&T'QOE�S NOT INCLUDE P CKX 09. BLOM
WALL,
)A C-ONSTRUCTIM ^,762.00 SF
C MUM,
vomalipKno, 284.00 SF
0ARA0U'CA1U>CAX3' 501.00 W
U-STATATED C0119T OF CONSTIVUCTION
2 8; 7M. 0; 0
PERMIT FRE SUMAIARV'
C 0 N STR. Ct C r 10 N YM,* 10t-000-419-0010 1101.00
P7, A W CNA TCK FT, R 10140-430�_118 S9910
NIRCHANICAL F1.7,111
PlXk,�MICAL FEE 101 -WO -420-000 $183.19
10.1-000-419-000 $1,81.7.5
WRONOMOT10'N Fr,�'.'-XESM 1014M-241-000
CIPUM.)INIC F11h 101-000-423-000
1NMANTRUCIVRE Fa-. 225-11ACH43-3,12
AWF (N PUSUC PLACES - RF00701-000-25,54M %_12.1.$9
rFF PFP031T 1011-00111-419-318 _$7S0.00
S'UTYRNAL COWSMUCTION ANDP!LAN 04fXX
$7,86A.93
LESS PRE -PAID FEES
4750.00
T(Y.CAL MUMIT YEKS DUE NOW
$7,110.93
1d3G DOW, NIZ)
C i -2 J \ 19. 10E "... I ,
I
RECEIPT
DATE
By
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
I DATE
I INSPECTOR
OPERATION I
DATE I
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade -7-
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T,O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS -SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam -
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines 57'_ 7,<_ZZ7—�
Water Piping
Heater Final
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
r Lateral ot 0
Pool Cover
S�wer Connection
Encapsulation
Mas Piping
Gas Test Z17
Appliances
Final
Final
Utility Notice (Gas) 2-- /Y 101 1 /0,0Z
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
LowVoltageWidrig
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm) Gr
COMMENTS:
I-_4 -I-
4� CL
oi-